Cognitive Processes and the Treatment of Obesity

There is a general consensus that the main drivers leading to weight regain are the biological pressure on individuals to overeat and the reduction of energy expenditure to restore their original weight, combined with exposure to an environment rich in highly palatable and hypercaloric foods, not to mention the availability of electronic devices, which intensifies the human predisposition to conserve energy.

However, data from the National Weight Control Registry (NWCR) clearly show that many people can overcome these pressures in the long term and maintain significant weight loss by adopting specific lifestyle modification behaviors (e.g., higher levels of intense physical activity, more frequent weight monitoring, and the adoption of behavioral strategies to control dietary intake). Unfortunately, this study was not designed to answer the central question raised by these results—namely, why some individuals continue practicing weight-control behaviors and, thus, maintain long-term weight loss, while others do not.

That said, since the "complex behaviors" involved in weight loss and maintenance through lifestyle modification are influenced by conscious cognitive processes, it is plausible that these may play an influential role in an individual's success or failure in maintaining lost weight.

Cognitive factors have been widely overlooked in traditional obesity treatments, but this hypothesis is supported by basic scientific research clearly demonstrating the role of cognitive processes in maintaining unhealthy eating habits and making it difficult to eat healthier. This is further supported by the results of some clinical studies that have respectively shown associations between specific cognitive factors and treatment discontinuation, as well as the amount of weight lost and the maintenance of long-term weight loss.

Unrealistic Weight Goals and Primary Goals

Studies conducted in Italy indicate that people starting a weight loss treatment have an average weight loss expectation of 32 percent, and often have "primary goals" (i.e., the goals they aim to reach with weight loss) not only related to improving health conditions (e.g., improving interpersonal relationships and/or self-confidence, finding a partner, or a new job). Available data indicate that these goals are unrealistic because there are no obesity treatments, including bariatric surgery, that have been shown to achieve a long-term average weight loss of more than 30 percent, and many non-health-related primary goals are often unattainable even with a significant weight loss.

The presence of unrealistic weight and primary goals seems to be associated with treatment discontinuation or failure to maintain lost weight, as people consider the achieved result unsatisfactory. Furthermore, people with unrealistic weight goals often intermittently adopt dysfunctional dietary restrictions, which contributes to triggering and maintaining overeating, dysregulated eating, and binge eating.

False Hope Syndrome

The popularity of dysfunctional diets has increased significantly in recent years, largely due to the "false hope syndrome," which the diet industry often exploits. False hope is based on the mistaken belief that change is easily attainable and will produce exaggerated benefits.

Regarding diet, studies have observed that people seem to behave paradoxically, persisting in repeated attempts at weight loss with incongruous diets, despite previous failures. Initial weight loss often provides a powerful positive reinforcement, even though it is then followed by failure because it often accompanies feelings of control and optimism.

Moreover, unrealistic expectations regarding ease, speed, the likely degree of weight loss, and the presumed benefits that will be obtained from weight loss tend to overwhelm the knowledge derived from previous failures. These failures often result from adopting a dysfunctional diet characterized by extreme and rigid dietary rules, which obviously cannot be maintained in the long term, to achieve unrealistic weight and primary goals.

The false hope of those following dysfunctional diets promoted by the diet industry reflects the desire to believe that one can get what one wants: False hopes develop because people want to believe in them.

Irrational Beliefs Associated With Eating

The Irrational Food Beliefs Scale (IFBS) is a self-administered instrument of 41 items investigating irrational beliefs associated with eating. The instrument was recently administered to a sample of 503 patients who sought treatment for clinical obesity and found the following six factors:

1. Self-deception on eating and weight control
2. Beliefs about eating and emotion regulation
3. Low tolerance for eating control
4. Beliefs about eating and hedonic pleasure
5. Beliefs about dieting
6. All-or-nothing thinking about eating

IFBS did not discriminate between patients with clinical obesity and a group of 45 controls without obesity. However, the absence of significant differences is not surprising because it would be simplistic to associate obesity with specific irrational thoughts about food. Indeed, there is growing evidence suggesting that clinical obesity is a chronic, relapsing, progressive disease process that may arise from different causes, including altered environments, personal situations, psychosocial factors, medications, diseases, trauma, iatrogenic procedures, and genetic and epigenetic variations.

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However, the study found that irrational food beliefs are more pronounced in the subgroup of patients with clinical obesity and binge-eating disorder and are more related to some eating-disorder psychological features and overvaluation of shape and weight than body weight.

Longitudinal studies are underway to assess whether the constructs of the IFBS play a significant role in the adoption and maintenance of dysfunctional eating habits and the failure of long-term weight control efforts.

Conclusions

Several studies found that specific cognitive factors are associated with attrition, while others are related to the amount of weight loss or the maintenance of long-term weight loss. It is also probable that they might influence the treatment outcome of patients treated with the new popular weight loss drugs, but future studies should test this speculation. However, despite their importance, cognitive factors are not usually addressed by the current treatment of obesity.

Future research is needed to evaluate the potential value of including specific procedures and strategies designed to address the cognitive variables associated with unfavorable treatment outcomes to improve the long-term efficacy of the management of clinical obesity.